<form action="report" name="report_$type_$id" method="post">
<input type="hidden" name="mode" value="$mode" />
<input type="hidden" name="type" value="$type" />
<input type="hidden" name="id" value="$id" />
<input type="hidden" name="referer" value="$referer" />
<table width="100%" border="0" cellspacing="0" cellpadding="2" bgcolor="$border">
  <tr>
    <td align="center" class="title" colspan="3">%report_dead_link%</td>
  </tr>
  <tr><td bgcolor="$pagebg"></td></tr>
  <tr>
    <td bgcolor="$bg1">%leave_description%</td>
  </tr>
  <tr>
    <td bgcolor="$bg2" align="center"><textarea name="description" cols="60" rows="5"></textarea>
    <br />$captcha_form</td>
  </tr>
  <tr>
    <td bgcolor="$bg1" align="center">
    <input type="submit" name="confirm" value="%report%" />
    <input type="reset" name="reset" value="%reset%" /></td>
  </tr>
</table>
</form>